How to set up a sentinel event response team
How to set up a sentinel event response team
Plan ahead to eliminate confusion in a chaotic time
(Editor’s note: Part one of HPR’s exclusive report on sentinel events looks at taking a team approach to sentinel event response and identifies the personnel who should make up the response team. In part two, we will detail a comprehensive action plan for evaluating and improving the processes that lead to sentinel events.)
Don’t assume that the systems you already have in place at your facility will be sufficient to help you respond effectively to a sentinel event, should one occur, experts caution. The chaos that often accompanies a sentinel event, both internally and often in the local media, can throw those systems into disarray. Often, it’s left to one individual — usually the risk manager — to develop and organize an appropriate response on the fly.
To reduce the possibility of confusion and allow your facility to quickly formulate a coherent and organized response, experts recommend that you plan ahead of time by developing a team specifically designed to handle sentinel events and assigning specific responsibilities to each team member.
That’s what staff at Denver-based Catholic Health Initiatives recommended for their system facilities for sentinel event response. Terri S. Karsten, JD, associate counsel for provider operations, and Nancy Lima, MBA, BSN, CPHQ, FNAHQ, director of performance improvement, both of Catholic Health Initiatives, recommend that the response team should, at a minimum, include the following individuals:
• Risk manager. The risk manager should play a role in initially determining whether an event is "sentinel," work to gather information about the event, perform an investigation, and contact legal counsel. The risk manager also should be tasked with serving as liaison to the hospital’s communications department; serve as contact person with the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations, government agencies, and the family of the patient involved in the sentinel event; and play a role in deciding whether to self-report the event to the Joint Commission. Because of the risk manager’s greater knowledge of sentinel event policies, the risk manager could serve as leader of the response team.
• Administration. Representatives from administration must be represented on the response team because of how the event might affect the facility’s accreditation status. Admini stra tion also must be involved in the decision of whether or not to self-report the event and should be available to provide support for remedial measures, internal enforcement efforts, and follow-up.
• Issue-specific representative and medical staff. Someone from the area in which the sentinel event occurred should be represented on the team to provide key information about the event. Medical staff also should be involved in the root-cause analysis and in the implementation of preventive measures to keep similar events from occurring in the future. Staff also can assist in monitoring progress and commenting on the need for further evaluation of the process that led to the sentinel event.
Don’t focus on individual blame
Although it’s important to have someone from the affected area on the team, it should not be the individual "responsible" for the sentinel event, cautions Lima. "There’s frequently a tendency to want to include the nurse involved or the pharmacist involved, and we really recommend against that," she says. "First of all, it’s kind of cruel and inhuman in a situation like this. If I was the nurse that made the medication error that caused a patient to die, I’m not going to be in any shape to participate." Also, Lima notes, this approach tends to focus the team on individual blame rather than on reforming the process behind the error. It’s better to include the supervisor of the individual involved. "That person is familiar with the process and knows the intimate details of the scenario, but is still a step removed from the incident," Lima says.
• Quality director. The quality director should be responsible for facilitating the root-cause analysis, applying continuous quality improvement tools in responding to the sentinel event, and assisting in determining whether or not to self-report the event to the Joint Commission.
"It’s critical to be able to have a strong facilitator to do a root-cause analysis to make sure that you’re asking the correct questions, that you continue to go beyond the people issue, and to make sure that you’re peeling that onion the next layer to address the appropriate systems and processes that may have been contributing factors," Lima says. "We suggest that the quality director may be an ideal person to do that."
Lima adds that the quality director also is in a good position to know what data currently are being collected. "Once you’ve identified the corrective actions that need to take place, it’s important to be able to analyze data to make sure the corrective actions have indeed been useful and helpful. The quality director is a good person to be able to facilitate that process as well," Lima says.
Once you’ve identified who should be on the team, it’s important to ensure that all team members can be reached at any time should a sentinel event occur. "For whatever reason, these types of events seem to occur at the oddest times of the day and night," Karsten says. "So there needs to be some mechanism, such as an on-call administrator, that allows the team to be able to assemble quickly." Karsten adds that, for times when a team member is scheduled to be away from the facility for an extended period of time, a trained backup should able to cover for the absent member. At a minimum, retain and distribute the addresses, day and evening telephone numbers, and pager numbers of all team members.
When a sentinel event does occur, it’s common for the response team to meet two or three times per week initially. "Then, as the process becomes narrowed, a lot of the media attention has dissipated and staff is back to the grind, you may not need to meet as often," Karsten says.
"The goal is to get this wrapped up and remedial measures instituted as soon as possible," Lima adds. "This is a wake-up call, because you’ve got something that’s terribly broken and needs to be fixed as soon as possible for the benefit of the rest of your patients. The 45-day window that the Joint Commission requires is not very much time to get all this together. This is a very intense and intensive process, and it’s not uncommon for teams to meet fairly frequently at first."
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